Doctoring

Thomas McKeown

A few years ago an American physician, Leon Kass, drew attention to a remarkable paradox: that at a time when medical knowledge is greater and technology more powerful than ever before, medicine is assailed by doubts about its role and purpose. Some reasons for the doubts are clear enough: uncertainty about the respective responsibilities of public and private agencies for the finance and administration of health services; rapidly rising costs of medical care and the lack of an acceptable basis for limiting them; gross inequalities in health between continents, between countries, and between different sections of the population of the same country; ethical issues which arise particularly from the ability to prolong or terminate life; and formidable problems of litigation attributable to the difficulty of distinguishing clearly between errors of clinical judgment and negligence. But perhaps the most telling source of uncertainty about medical activities is the possibility that we have overestimated what has been achieved, indeed what can be achieved, by treatment of the sick. We begin to suspect that some disease problems may prove to be, as J.B.S. Haldane said of the universe, ‘not only queerer than we suppose but queerer than we can suppose’.

These issues have attracted the attention of many critics of medicine – a term applied indiscriminately to all who question the conventional reading of medical goals and achievements – and most of the points discussed by Ian Kennedy in the 1981 Reith Lectures have been raised before. Nevertheless, his legal approach is novel, and the lectures themselves were well-organised and delivered with remarkable force and clarity. Whatever their reservations about the conclusions, many doctors will have been glad to hear these important matters examined before a large general audience. The book now published comprises the lectures, slightly extended, a bibliography, and an additional chapter which enlarges the discussion of three topical issues: the role of technology in medicine, the care of the dying and the determination of death.

It is pointless to object that Kennedy writes as a lawyer rather than as a physician or administrator: that he does not, for example, present the grounds for thinking that the main determinants of health are outside the medical care system or discuss ways in which the right balance could be achieved between preventive and therapeutic measures. His stance is that of a prosecutor who accuses the medical profession on two main counts: that they have taken the wrong approach to the preservation of health and that they have usurped the rights of the public by accepting responsibility for many moral and ethical decisions which are quite outside their field of competence. He is somewhat disarmed from the outset by the fact that many doctors readily concede some of the points on which he bases his case: that concepts of illness and health are imprecise and involve social and economic as well as medical judgments; that much greater emphasis is needed on the prevention of disease and the promotion of health; that many problems with which medicine is faced – contraception, abortion, screening for disease, prolongation of the lives of the handicapped, the control of technology, and so on – are matters for public debate and decision. There are, nevertheless, several issues on which sharp differences of opinion are likely to arise.

Perhaps the most basic, certainly the most sensitive question is the regard in which medicine is held. Does it justify the respect it has usually been accorded? Illich took the view that, on balance, medicine does more harm than good and that little would be lost if most of its services were abandoned. Kennedy has the good sense to put some distance between himself and this position, although he comes perilously close to it when he writes that ‘the nature of modern medicine makes it positively deleterious to the health and well-being of the population.’ I do not believe that this view is consistent either with an objective appraisal of medical achievement or with experience of the care of the sick at home or in hospital. Without the understanding provided by medical science our hold on the developments – nutritional, environmental, behavioural and medical – which have transformed health since the 18th century would be as precarious as the advances in Roman hygiene proved to be, and there must be few people who complete their lives without having reason to be grateful to the medical and nursing services for their own or their relatives’ personal care. ‘It is hard to avoid the conclusion,’ Kennedy says, ‘that the National Health Service has failed us’: a statement that could hardly have been made by anyone old enough to have had personal experience of the situation before the 1948 Act. For all its faults, the NHS has made medical care available to everyone and has removed the burden of direct payment from the large number of people who could ill afford it – an achievement which has not yet been matched in some of the wealthiest countries.